Clinical documentation is central to patient care. The success of electronic health record system adoption may depend on how well such systems support clinical documentation. A major goal of integrating clinical documentation into electronic heath record systems is to generate reusable data. As a result, there has been an emphasis on deploying computer-based documentation systems that prioritize direct structured documentation. Research has demonstrated that healthcare providers value different factors when writing clinical notes, such as narrative expressivity, amenability to the existing workflow, and usability. The authors explore the tension between expressivity and structured clinical documentation, review methods for obtaining reusable data from clinical notes, and recommend that healthcare providers be able to choose how to document patient care based on workflow and note content needs. When reusable data are needed from notes, providers can use structured documentation or rely on post-hoc text processing to produce structured data, as appropriate.

Previous investigators have defined clinical interface terminology as a systematic collection of health care-related phrases (terms) that supports clinicians' entry of patient-related information into computer programs, such as clinical "note capture" and decision support tools. Interface terminologies also can facilitate display of computer-stored patient information to clinician-users. Interface terminologies "interface" between clinicians' own unfettered, colloquial conceptualizations of patient descriptors and the more structured, coded internal data elements used by specific health care application programs. The intended uses of a terminology determine its conceptual underpinnings, structure, and content. As a result, the desiderata for interface terminologies differ from desiderata for health care-related terminologies used for storage (e.g., SNOMED-CT), information retrieval (e.g., MeSH), and classification (e.g., ICD9-CM). Necessary but not sufficient attributes for an interface terminology include adequate synonym coverage, presence of relevant assertional knowledge, and a balance between pre- and post-coordination. To place interface terminologies in context, this article reviews historical goals and challenges of clinical terminology development in general and then focuses on the unique features of interface terminologies.

Preventive care measures remain underutilized despite recommendations to increase their use. The objective of this review was to examine the characteristics, types, and effects of paper- and computer-based interventions for preventive care measures. The study provides an update to a previous systematic review. We included randomized controlled trials that implemented a physician reminder and measured the effects on the frequency of providing preventive care. Of the 1,535 articles identified, 28 met inclusion criteria and were combined with the 33 studies from the previous review. The studies involved 264 preventive care interventions, 4,638 clinicians and 144,605 patients. Implementation strategies included combined paper-based with computer generated reminders in 34 studies (56%), paper-based reminders in 19 studies (31%), and fully computerized reminders in 8 studies (13%). The average increase for the three strategies in delivering preventive care measures ranged between 12% and 14%. Cardiac care and smoking cessation reminders were most effective. Computer-generated prompts were the most commonly implemented reminders. Clinician reminders are a successful approach for increasing the rates of delivering preventive care; however, their effectiveness remains modest. Despite increased implementation of electronic health records, randomized controlled trials evaluating computerized reminder systems are infrequent.

The COVID-19 national emergency has led to surging care demand and the need for unprecedented telehealth expansion. Rapid telehealth expansion can be especially complex for pediatric patients. From the experience of a large academic medical center, this report describes a pathway for efficiently increasing capacity of remote pediatric enrollment for telehealth while fulfilling privacy, security, and convenience concerns. The design and implementation of the process took 2 days. Five process requirements were identified: efficient enrollment, remote ability to establish parentage, minimal additional work for application processing, compliance with guidelines for adolescent autonomy, and compliance with institutional privacy and security policies. Weekly enrollment subsequently increased 10-fold for children (age 0–12 years) and 1.2-fold for adolescents (age 13–17 years). Weekly telehealth visits increased 200-fold for children and 90-fold for adolescents. The obstacles and solutions presented in this report can provide guidance to health systems for similar challenges during the COVID-19 response and future disasters.